Protecting Reproductive Health and Choice

Women and men have special needs in rehabilitation. Women''s needs, however, have received far less attention in the scientific community and medical literature. This section, edited by Sandra Cole, PhD,^* highlights some of the unique concerns of women who live with physical disabilities.     

Rehabilitation in the Philippines

The international community has perspective and experience that will freshen our approaches to rehabilitation. Martin Grabois, MD^*, editor of this special section, has gathered articles written by experts from other countries. The intention is to stimulate thought, discussion, and action—and to broaden horizons.     

Excitation Energy Transfer between Pigments in Photosynthetic Cells

The excitation lifetimes of photosynthetic pigments and the times needed for energy transfer between pigments in various algae, were determined in vitro and in vivo. For this purpose, the time curves of fluorescence rise and decay were measured by means of Brody''s instrument (10), and compared with theoretical curves obtained by the method of “convolution of the first kind.”¹     

Administration of Blood By Registered Nurses—Joint Statement by California Medical Association,California Hospital Association and California Nurses' Association

After several years of favorable experience with registered nurses giving intravenous injections of fluids under the criteria set out in a joint statement by the California Medical Association, the California Hospital Association and the California Nurses'' Association,^* it was proposed that it would be appropriate for registered nurses to administer blood. Careful study of current experience in various places with registered nurses giving blood transfusions convinced a joint committee that it recommend the adoption of the following statement which was approved by the associations indicated.     

Cushing Syndrome: Current Concepts of Diagnosis and Therapy

A variety of diagnostic advances including radioimmunoassay of adrenocorticotropic hormone (ACTH) have increased the number of methods for laboratory investigation of Cushing syndrome.^* However, experience with these procedures has led to a recognition of their limitations. We have developed an algorithm which incorporates these newer techniques and minimizes the number of procedures required to diagnose the various causes of Cushing syndrome. At present, we recommend pituitary surgical operations for pituitary-dependent Cushing syndrome because we believe this disease is caused by the development of a pituitary ACTH-secreting tumor.     

The Operative Management of Crohn Disease

The natural history of Crohn disease^* is varied and unpredictable, and its cause is not known. No modality of treatment has definitely been shown to alter its course.Surgical treatment was carried out in a consistent fashion in 141 consecutive patients with Crohn disease. The indications for surgical operation were the complications of the disease only; these included fistula, abscess, obstruction and hemorrhage. Preoperative evaluation included upper gastrointestinal examination, barium enema, intravenous pyelogram, proctoscopy, and nutritional and volume support. In 76 of these patients previous operations had been carried out for Crohn disease.The surgical treatment was based upon the specific complication present, with adherence to the principle of resection of diseased tissue only. Ureterolysis also was necessary in 20 percent of these patients. The operative mortality was 1.4 percent, postoperative complications occurred in 54 patients and the surgical recurrence rate was 26 percent. A favorable result was accomplished in 85 percent of the patients.     

Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure

Background:

Early physician follow-up after discharge is associated with lower rates of death and readmission among patients with heart failure. We explored whether physician continuity further influences outcomes after discharge.

Methods:

We used data from linked administrative databases for all adults aged 20 years or more in the province of Alberta who were discharged alive from hospital between January 1999 and June 2009 with a first-time diagnosis of heart failure. We used Cox proportional hazard models with time-dependent covariates to analyze the effect of follow-up with a familiar physician within the first month after discharge on the primary outcome of death or urgent all-cause readmission over 6 months. A familiar physician was defined as one who had seen the patient at least twice in the year before the index admission or once during the index admission.

Results:

In the first month after discharge, 5336 (21.9%) of the 24 373 identified patients had no follow-up visits, 16 855 (69.2%) saw a familiar physician, and 2182 (9.0%) saw unfamiliar physician(s) exclusively. The risk of death or unplanned readmission during the 6-month observation period was lower among patients who saw a familiar physician (43.6%; adjusted hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.83–0.91) or an unfamiliar physician (43.6%; adjusted HR 0.90, 95% CI 0.83–0.97) for early follow-up visits, as compared with patients who had no follow-up visits (62.9%). Taking into account all follow-up visits over the 6-month period, we found that the risk of death or urgent readmission was lower among patients who had all of their visits with a familiar physician than among those followed by unfamiliar physicians (adjusted HR 0.91, 95% CI 0.85–0.98).

Interpretation:

Early physician follow-up after discharge and physician continuity were both associated with better outcomes among patients with heart failure. Research is needed to explore whether physician continuity is important for other conditions and in settings other than recent hospital discharge.Hospital care accounts for almost one-third of health care spending, and unplanned readmissions within 30 days after discharge cost more than $20 billion each year in the United States and Canada.¹ Heart failure is one of the most common reasons for admission to hospital and is associated with a high risk of readmission.¹ Although the prognosis for patients with heart failure has improved over the past decade, the risk of early death or readmission after discharge is still high and is increasing.² Prompt follow-up of patients with heart failure has been associated with lower rates of death and readmission,^3,4 and 30-day follow-up has been included as a quality-of-care indicator in Canada.⁵It is unclear, however, whether the postdischarge visits should be with the physician who previously saw the patient or with any physician. Results of studies exploring the association between provider continuity and postdischarge outcomes have been inconclusive and the studies have included few patients with heart failure.^6–9 Intuitively, one might consider physician continuity important for patients with heart failure discharged from hospital, given their age, high comorbidity burdens and complex treatment regimens. However, a robust evidence base and multiple guidelines with consistent messaging on key management principles have made physician continuity potentially less important.We designed this study to determine whether physician continuity influenced postdischarge outcomes among patients with heart failure beyond the influence of early physician follow-up.     

Combination of MS Protein Identification and Bioassay of Chromatographic Fractions to Identify Biologically Active Substances from Complex Protein Sources

Purification of biologically active proteins from complex biological sources is a difficult task, usually requiring large amounts of sample and many separation steps. We found an active substance in a serum response element-dependent luciferase reporter gene bioassay in interstitial cystitis urine that we attempted to purify with column chromatography and the bioassay. With anion-exchange Mono Q and C₄ reversed-phase columns, apparently sharp active peaks were obtained. However, more than 20 kinds of proteins were identified from the active fractions with MS, indicating that the purification was not complete. As further purification was difficult, we chose a candidate molecule by means of studying the correlation between MS protein identification scores and bioassay responses of chromatographic fractions near the active peaks. As a result, epidermal growth factor (EGF) was nominated as a candidate molecule among the identified proteins because the elution profile of EGF was consistent with that of the bioassay, and the correlation coefficient of EGF between MS protein identification scores and bioassay responses was the highest among all the identified proteins. With recombinant EGF and anti-EGF and anti-EGF receptor antibodies, EGF was confirmed to be the desired substance in interstitial cystitis urine. This approach required only 20 ml of urine sample and two column chromatographic steps. The combination of MS protein identification and bioassay of chromatographic fractions may be useful for identifying biologically active substances from complex protein sources.Purification and identification of biologically active proteins existing in minute amounts from biological sources such as urine is still a difficult task (1). It requires a large volume of the sample and many separation steps for purification (2, 3). Nevertheless the recent progress of MS has dramatically changed protein analysis (4). With MS, smaller protein samples can be used than with classical protein identification methods such as N-terminal peptide sequencing.Interstitial cystitis (IC)¹ is a chronic inflammatory disease characterized by frequency and urgency and/or severe pelvic pain (5). The International Continence Society also selected the term “painful bladder syndrome” for IC (6). The quality of life of IC patients is extremely low because of their severe symptoms. The pathogenesis of IC is unclear, and effective treatments have not been established. To elucidate the mechanism of IC pathogenesis, we attempted to find characteristic proteins in IC urine using proteomics techniques and have already reported active neutrophil elastase as an IC urinary marker (7). We had also performed gene expression analysis of IC bladder tissues using GeneChip technology and found that mRNA expression of GPR18, a member of the G-protein-coupled receptors, was higher in IC bladder than in the control.² We tried to confirm whether GPR18 endogenous ligand existed in IC urine by using a bioassay with GPR18 transfectant cells.In the present study, the existence of an active substance in IC urine was suggested in the bioassay using the serum response element (SRE)-dependent luciferase reporter gene with the stable recombinant HEK293 cell line expressing GPR18. We thought that the response was derived from GPR18 and tried to purify the active substance from a small volume of IC urine using chromatographic techniques. Among the many proteins identified from partially purified samples, we clearly nominated epidermal growth factor (EGF) as a candidate molecule judging from the correlation between MS protein identification and the bioassay of chromatographic fractions. With recombinant EGF and anti-EGF antibody, EGF was confirmed to be the desired substance found in IC urine. The complete inhibition of the bioassay response by anti-EGF receptor antibody also indicated that the response was based on the EGF receptor, not GPR18, suggesting that GPR18 overexpression enhanced the EGF signal via the endogenous EGF receptor of the HEK293 cell line.     

Stereochemistry and Stereoelectronics of Azines. 13. Conformational Effects on the Quadrupolarity of Azines. An Ab Initio Quantum-Mechanical Study of a Lateral Synthon

The quadrupole moment of formaldazine, H₂C=N-N=CH₂, has been studied for the trans structure (Ð(C-N-N-C) = = 180) and a series of gauche structures ( > 120). Restricted Hartree-Fock theory, second-order Møller-Plesset theory, and quadratic CI theory have been used in conjunction with the basis sets 6-31G^*, 6-31G**, 6-311G** and 6-311++G**. Formaldazine is a quadrupolar molecule with primitive quadrupole moment tensor components of Q _xx = -22.4, Q _yy = -20.4 and Q _zz = -25.6 DÅ at the theoretical level QCISD/6-311++G**. The examination of the theoretical level dependency shows that the reliable computation of a quadrupole moment requires the use of a flexible basis set. A large part of the component Q _zz = -25.6 DÅ is due to the -system and compares, on a per electron basis, with the Q _zz value of benzene. Conformational changes of the azines in the range 120° < < 180 have but a minute effect on the energy and are associated with only minor electronic relaxation. These conformational changes alter the quadrupole moment tensor components less than Q _xx = +0.4, Q _yy = +1.6 and Q _zz = -1.0 DÅ at QCISD/6-311++G**//QCISD/6-31G*. The direction of these changes is explained by consideration of the rotation of the CN--systems and a small reduction of the CN bond polarity in the gauche structures. The Q _zz component of formaldazine is representative of the quadrupole moment tensor component along the direction of the C ₂ axis of the azine bridge as such. Hence, the results of this study suggest that azines can engage in strong quadrupole-quadrupole interactions and can be employed as lateral synthons in crystal engineering. Electronic Supplementary Material available.     

Impact of specialist follow-up in outpatients with congestive heart failure

Background

There is uncertainty about whether physician specialty influences the outcomes of outpatients with congestive heart failure after adjustment for differences in case mix. Our objective was to determine the impact of physician specialty on outcomes in outpatients with new-onset congestive heart failure.

Methods

The study was a population-based retrospective cohort study involving patients with new-onset congestive heart failure discharged from 128 acute care hospitals in Alberta between Apr. 1, 1998, and July 1, 2000. Outcomes were resource utilization (clinic visits, emergency department visits and hospital admissions) and survival at 30 days and 1 year.

Results

A total of 3136 patients were discharged from hospital with a new diagnosis of congestive heart failure (median age 76 years, 50% men). Of these, 1062 (34%) received no follow-up visits for cardiovascular care, 738 (24%) were seen by a family physician (FP) alone, 29 (1%) by a specialist (cardiologist or general internist) alone and 1307 (42%) by both a specialist and an FP. Compared with patients who received no follow-up cardiovascular care, patients who received regular cardiovascular follow-up visits with a physician had fewer visits to the emergency department (38% v. 80%), fewer were admitted to hospital (13% v. 94%), and the adjusted 1-year mortality was lower (22% v. 37%) (all p < 0.001). Compared with patients who received combined specialist and FP care, patients cared for exclusively by FPs had fewer outpatient visits (median 9 v. 17 in the first year), fewer of these patients presented to the emergency department (24% v. 45% in the first year), and fewer were readmitted for cardiovascular care (7% v. 16%) (all p < 0.001). However, the adjusted mortality at 1 year was lower among patients treated with combined care (17% v. 28%, p < 0.001) despite a higher burden of comorbidities. In a multivariate model adjusting for comorbidities (with no cardiovascular follow-up visits as the reference category), the mortality was lower among patients followed on an outpatient basis by an FP alone (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.53–0.82) or by an FP and a specialist (OR 0.34, 95% CI 0.28–0.42). In a proportional hazards model with time-dependent covariates (with adjustment for frequency of follow-up visits), the risk of all-cause mortality was reduced significantly (hazard ratio 0.98, 95% CI 0.97– 0.99) with each specialist visit compared with FP care alone.

Interpretation

Patients with congestive heart failure followed by both specialists and FPs had significantly better survival than those followed by FPs alone (or those who received no specific cardiovascular follow-up care). Methods to improve timely and appropriate access to specialists and to improve collaborative care structures are needed.Congestive heart failure (CHF) afflicts up to 2% of North American adults and, despite many advances in diagnosis and therapy, still portends a poor prognosis, with 1-year mortality of 30%–50%.^1,2,3,4,5 Although the prognosis of patients with CHF is poor even with optimal management, suboptimal diagnosis, investigation and treatment of heart failure and comorbidities (e.g., coronary artery disease) in community-dwelling patients contributes to poor survival.^6,7,8,9In previous studies hospital inpatients with CHF who were cared for by specialists received more evidence-based therapies and had better outcomes than those cared for by nonspecialists.^{8,10,11,12,13} However, none of these studies examined the care delivered after discharge from hospital. Although management in specialized multidisciplinary clinics is associated with better outcomes,¹⁴ it is unclear whether similar benefits can be expected when patients are cared for by specialist physicians operating outside the setting of a multidisciplinary clinic. Two recent studies from the United States that reported better outcomes with specialist care^7,15 were flawed, in that neither study adjusted for frequency of outpatient visits or the possibility of time-dependent bias¹⁶ (whereby some variables, including the number of visits, will change over time).To address this important public health issue, we sought to determine whether there is a relation between ambulatory care follow-up and outcomes in patients with new-onset CHF.     

Factors associated with physician follow-up among patients with chest pain discharged from the emergency department

Background:

Many patients with chest pain do not receive follow-up from a physician after discharge from the emergency department despite significant survival benefit associated with follow-up care. Our objective was to evaluate factors associated with physician follow-up to understand this gap in practice.

Methods:

We conducted an observational study involving patients at high risk who were assessed for chest pain and discharged from an emergency department in Ontario between April 2004 and March 2010. We used multivariable logistic regression to determine the association of clinical and nonclinical characteristics with physician follow-up.

Results:

We identified 56 767 patients, of whom 25.1% did not receive any follow-up by a physician, 69.0% were seen by their primary care physician, and 17.3% were seen by a cardiologist within 30 days. Patients who had medical comorbidities and cardiac conditions such as myocardial infarction or heart failure were less likely to have follow-up. In contrast, a previous visit to a primary care physician was associated with the highest odds of having physician follow-up (odds ratio [OR] 6.44, 95% confidence interval [CI] 5.91–7.01). Similarly, a previous visit to a cardiologist was strongly associated with follow-up by a cardiologist (OR 3.01, 95% CI 2.85–3.17). Patients evaluated in emergency departments with the highest tertile of chest pain volume were more likely to receive follow-up from any physician (OR 1.52, 95% CI 1.31–1.77) and from a cardiologist (OR 2.04, 95% CI 1.61–2.57).

Interpretation:

Nonclinical factors are strongly associated with physician follow-up for patients with chest pain after discharge from the emergency department. However, patients with comorbidities and at higher risk for future adverse events are less likely to receive follow-up care.Chest pain is one of the most common presenting symptoms in emergency departments. In Canada, about 500 000 visits to the emergency department are related to chest pain assessment each year.¹ Most of these visits result in discharge after excluding a cardiac diagnosis with an immediate risk of adverse effect.² Current clinical guidelines strongly advocate for patients with chest pain who have been discharged from the emergency department to receive outpatient follow-up with a physician within 72 hours for further assessment or treatment, because many patients remain at risk for future events.³Among patients at high baseline cardiovascular risk who were discharged from the emergency department after assessment of chest pain, our group has previously shown significantly reduced hazard of death or myocardial infarction associated with follow-up with either a primary care physician or a cardiologist within 30 days.² At 1-year postassessment, the rate of death or myocardial infarction was 5.5% among patients who received cardiologist follow-up, 7.7% with primary care follow-up and 8.6% with no physician follow-up.² In addition, we found a considerable gap in practice, with 1 in 4 high-risk patients with chest pain failing to follow-up with a physician within 30 days of assessment in Ontario, Canada.² A better understanding of why physician follow-up does not occur in accordance with guidelines is essential to improve the transition of care from the emergency department to home. Thus, the main objective of our study was to evaluate clinical and nonclinical factors associated with physician follow-up among patients with chest pain after discharge from the emergency department.     

Human ACAP2 is a homolog of C. elegans CNT-1 that promotes apoptosis in cancer cells

Activation of caspases is an integral part of the apoptotic cell death program. Collectively, these proteases target hundreds of substrates, leading to the hypothesis that apoptosis is “death by a thousand cuts”. Recent work, however, has demonstrated that caspase cleavage of only a subset of these substrates directs apoptosis in the cell. One such example is C. elegans CNT-1, which is cleaved by CED-3 to generate a truncated form, tCNT-1, that acquires a potent phosphoinositide-binding activity and translocates to the plasma membrane where it inactivates AKT survival signaling. We report here that ACAP2, a homolog of C. elegans CNT-1, has a pro-apoptotic function and an identical phosphoinositide-binding pattern to that of tCNT-1, despite not being an apparent target of caspase cleavage. We show that knockdown of ACAP2 blocks apoptosis in cancer cells in response to the chemotherapeutic antimetabolite 5-fluorouracil and that ACAP2 expression is down-regulated in some esophageal cancers, leukemias and lymphomas. These results suggest that ACAP2 is a functional homolog of C. elegans CNT-1 and its inactivation or downregulation in human cells may contribute to cancer development.The caspases (cysteine aspartic acid proteases) are a class of proteases with diverse roles in cellular physiology including differentiation, inflammation and cell death.^1–3 Caspases play a critical role in apoptosis, where they collectively target hundreds of proteins. One prevailing view is that caspases drive apoptosis through a mass action effect due to hundreds of proteolytic cleavage events that lead to cellular disassembly and cell death.⁴ Recent studies, however, suggest that proteolysis of most substrates may simply be a bystander effect and that caspase cleavage of key proteins controlling a few specific cellular processes is what functionally drives apoptosis.⁵ Although much of the work to date has focused on factors acting upstream of caspase activation, it is becoming increasingly clear that events downstream of this commitment step are also tightly regulated and critically important for apoptosis. Presently, there is evidence of requirements for caspase-mediated control of the BCL2 family of anti-apoptotic proteins, mitochondrial elimination, chromosome fragmentation, phosphatidylserine externalization, and, as we have recently reported, inactivation of the AKT survival signaling pathway in programmed cell death (6-10 Therefore, a more thorough understanding of physiologically relevant caspase targets will increase our understanding of apoptosis in the context of animal development and disease.

Table 1

Human homologues of functional caspase targets in C. elegans. A summary of identified caspase substrates and caspase downstream events important for cell death execution in C. elegans and humans

Independent associations between low-density lipoprotein cholesterol and cancer among patients with type 2 diabetes mellitus

Background

The risk association between low-density lipoprotein (LDL) cholesterol and cancer remains controversial and largely unexplored for people not receiving statin therapy.

Methods

We examined the risk association between LDL cholesterol and cancer among patients with type 2 diabetes mellitus who were free of cancer at enrolment and whose statin use was known. We considered a variety of nonlinear relationships in our analysis.

Results

During a median follow-up period of 4.90 years, cancer developed in 270 (4.4%) of 6107 patients. Among the 3800 patients who did not receive statin therapy, the risk association between LDL cholesterol and cancer was represented by a V-shaped curve. Compared with patients whose LDL cholesterol was at least 2.80 mmol/L but less than 3.80 mmol/L, the risk of cancer, death from any cause or the composite outcome of cancer or death was greater among those with an LDL cholesterol level of less than 2.80 mmol/L (hazard ratio for cancer 1.74, 95% confidence interval [CI] 1.20–2.52) and those with an LDL cholesterol level of 3.80 mmol/L or greater (hazard ratio for cancer 1.87, 95% CI 1.29–2.71). Using 3.8 mmol/L as a reference point, we found that the hazard ratio for cancer for every millimole per litre absolute change in LDL cholesterol was 1.54 (95% CI 1.19–1.99) among patients not using statins; the hazard ratio was reduced to 1.24 (1.01–1.53) for the entire sample (statin users and those not using statins). These associations persisted after adjustment for covariates and exclusion of patients with less than 2.5 years of follow-up.

Interpretation

Among patients with type 2 diabetes, the association between LDL cholesterol and cancer was V-shaped, whereby both low and high levels of LDL cholesterol were associated with elevated risk of cancer.Emerging data suggest an association between diabetes mellitus and an increased risk of cancer,¹ including breast cancer in women;² colorectal,³ pancreatic^4,5 and liver⁶ cancer in both men and women; and prostate cancer in men.⁷ Several prospective analyses, including the US National Health and Nutrition Examination Survey,⁸ have demonstrated an inverse relation between serum total cholesterol and cancer incidence and mortality in the general population, although few studies have investigated this relation among patients with type 2 diabetes mellitus. In 2004, the US National Cholesterol Education Program Adult Treatment Panel III recommended treatment targets for low-density lipoprotein (LDL) cholesterol of less than 1.81 mmol/L (less than 70 mg/dL) for patients with very high risk of coronary artery disease and less than 2.59 mmol/L (less than 100 mg/dL) for patients with high risk of coronary artery disease;⁹ these targets were intended for both diabetic and nondiabetic patients.These recommendations remain controversial. Although one recent analysis of a large cohort of patients treated with statins showed a greater risk of cancer with achievement of low LDL cholesterol,¹⁰ a more recent study reported otherwise.¹¹ Furthermore, the independent associations between LDL cholesterol level and cancer in both the general population and in patients with type 2 diabetes have not been explored. We conducted a hypothesis-generating study to explore the possible independent association between LDL cholesterol and cancer risk in Chinese patients with type 2 diabetes mellitus.     

Ecological networks: delving into the architecture of biodiversity

In recent years, the analysis of interaction networks has grown popular as a framework to explore ecological processes and the relationships between community structure and its functioning. The field has rapidly grown from its infancy to a vibrant youth, as reflected in the variety and quality of the discussions held at the first international symposium on Ecological Networks in Coimbra—Portugal (23–25 October 2013). The meeting gathered 170 scientists from 22 countries, who presented data from a broad geographical range, and covering all stages of network analyses, from sampling strategies to effective ways of communicating results, presenting new analytical tools, incorporation of temporal and spatial dynamics, new applications and visualization tools.¹ During the meeting it became evident that while many of the caveats diagnosed in early network studies are successfully being tackled, new challenges arise, attesting to the health of the discipline.     

Metformin and low levels of thyroid-stimulating hormone in patients with type 2 diabetes mellitus

Background:

Small cross-sectional studies have suggested that metformin, a first-line oral hypoglycemic agent, may lower thyroid-stimulating hormone (TSH) levels. Our objective was to determine whether the use of metformin monotherapy, when compared with sulfonylurea monotherapy, is associated with an increased risk of low TSH levels (< 0.4 mIU/L) in patients with type 2 diabetes mellitus.

Methods:

Using the Clinical Practice Research Datalink, we identified patients who began receiving metformin or sulfonylurea monotherapy between Jan. 1, 1988, and Dec. 31, 2012. We assembled 2 subcohorts of patients with treated hypothyroidism or euthyroidism, and followed them until Mar. 31, 2013. We used Cox proportional hazards models to evaluate the association of low TSH levels with metformin monotherapy, compared with sulfonylurea monotherapy, in each subcohort.

Results:

A total of 5689 patients with treated hypothyroidism and 59 937 euthyroid patients were included in the subcohorts. Among patients with treated hypothyroidism, 495 events of low TSH levels were observed during follow-up (incidence rate 119.7/1000 person-years). In the euthyroid group, 322 events of low TSH levels were observed (incidence rate 4.5/1000 person-years). Compared with sulfonylurea monotherapy, metformin monotherapy was associated with a 55% increased risk of low TSH levels in patients with treated hypothyroidism (incidence rate 79.5/1000 person-years v. 125.2/1000 person-years, adjusted hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.09–2.20), with the highest risk in the 90–180 days after initiation (adjusted HR 2.30, 95% CI 1.00–5.29). No association was observed in euthyroid patients (adjusted HR 0.97, 95% CI 0.69–1.36).

Interpretation:

In this longitudinal population-based study, metformin use was associated with an increased incidence of low TSH levels in patients with treated hypothyroidism, but not in euthyroid patients. The clinical consequences of this need further investigation.Metformin, a first-line oral hypoglycemic agent for the treatment of type 2 diabetes mellitus, improves hepatic insulin resistance and reduces glucose production.¹ However, despite its excellent safety profile,² studies have suggested that its use may lower thyroid-stimulating hormone (TSH) levels in patients with diabetes and hypothyroidism.^3–9 In some studies, the use of metformin was associated with reductions in TSH levels below the reference range,^4–7 potentially exposing patients to the harmful consequences of subclinical hyperthyroidism (e.g., cardiovascular conditions and fractures¹⁰). In contrast, metformin was not associated with changes to TSH levels in euthyroid patients.¹¹ Given the methodologic shortcomings of the few studies conducted to date (i.e., small samples, cross-sectional designs and no active comparator), it remains uncertain whether the use of metformin is associated with an increased risk of low TSH levels in patients with hypothyroidism or euthyroidism and type 2 diabetes.Given the widespread use of metformin in patients with type 2 diabetes and the potential negative consequences of low TSH levels, there is a need to assess the incidence and magnitude of this biochemical event in the natural setting of clinical practice. Thus, the objective of this large population-based study was to determine whether the use of metformin monotherapy, when compared with sulfonylurea monotherapy, is associated with an increased risk of low TSH levels (< 0.4 mIU/L) in patients with treated hypothyroidism or euthyroidism and type 2 diabetes.     

IDEAL-Q, an Automated Tool for Label-free Quantitation Analysis Using an Efficient Peptide Alignment Approach and Spectral Data Validation

In this study, we present a fully automated tool, called IDEAL-Q, for label-free quantitation analysis. It accepts raw data in the standard mzXML format as well as search results from major search engines, including Mascot, SEQUEST, and X!Tandem, as input data. To quantify as many identified peptides as possible, IDEAL-Q uses an efficient algorithm to predict the elution time of a peptide unidentified in a specific LC-MS/MS run but identified in other runs. Then, the predicted elution time is used to detect peak clusters of the assigned peptide. Detected peptide peaks are processed by statistical and computational methods and further validated by signal-to-noise ratio, charge state, and isotopic distribution criteria (SCI validation) to filter out noisy data. The performance of IDEAL-Q has been evaluated by several experiments. First, a serially diluted protein mixed with Escherichia coli lysate showed a high correlation with expected ratios and demonstrated good linearity (R² = 0.996). Second, in a biological replicate experiment on the THP-1 cell lysate, IDEAL-Q quantified 87% (1,672 peptides) of all identified peptides, surpassing the 45.7% (909 peptides) achieved by the conventional identity-based approach, which only quantifies peptides identified in all LC-MS/MS runs. Manual validation on all 11,940 peptide ions in six replicate LC-MS/MS runs revealed that 97.8% of the peptide ions were correctly aligned, and 93.3% were correctly validated by SCI. Thus, the mean of the protein ratio, 1.00 ± 0.05, demonstrates the high accuracy of IDEAL-Q without human intervention. Finally, IDEAL-Q was applied again to the biological replicate experiment but with an additional SDS-PAGE step to show its compatibility for label-free experiments with fractionation. For flexible workflow design, IDEAL-Q supports different fractionation strategies and various normalization schemes, including multiple spiked internal standards. User-friendly interfaces are provided to facilitate convenient inspection, validation, and modification of quantitation results. In summary, IDEAL-Q is an efficient, user-friendly, and robust quantitation tool. It is available for download.Quantitative analysis of protein expression promises to provide fundamental understanding of the biological changes or biomarker discoveries in clinical applications. In recent years, various stable isotope labeling techniques, e.g. ICAT (1), enzymatic labeling using ¹⁸O/¹⁶O (2, 3), stable isotope labeling by amino acids in cell culture (4), and isobaric tagging for relative and absolute quantitation (2, 5), coupled with LC-MS/MS have been widely used for large scale quantitative proteomics. However, several factors, such as the limited number of samples, the complexity of procedures in isotopic labeling experiments, and the high cost of reagents, limit the applicability of isotopic labeling techniques to high throughput analysis. Unlike the labeling approaches, the label-free quantitation approach quantifies protein expression across multiple LC-MS/MS analyses directly without using any labeling technique (7–9). Thus, it is particularly useful for analyzing clinical specimens in highly multiplexed quantitation (10, 11); theoretically, it can be used to compare any number of samples. Despite these significant advantages, data analysis in label-free experiments is an intractable problem because of the experimental procedures. First, although high reproducibility in LC is considered a critical prerequisite, variations, including the aging of separation columns, changes in sample buffers, and fluctuations in temperature, will cause a chromatographic shift in retention time for analytes in different LC-MS/MS runs and thus complicate the analysis. In addition, under the label-free approach, many technical replicate analyses across a large number of samples are often acquired; however, comparing a large number of data files further complicates data analysis and renders lower quantitation accuracy than that derived by labeling methods. Hence, an accurate, automated computation tool is required to effectively solve the problem of chromatographic shift, analyze a large amount of experimental data, and provide convenient user interfaces for manual validation of quantitation results.The rapid emergence of new label-free techniques for biomarker discovery has inspired the development of a number of bioinformatics tools in recent years. For example, Scaffold (Proteome Software) and Census (12) process PepXML search results to quantify relative protein expression based on spectral counting (13–15), which uses the number of MS/MS spectra assigned to a protein to determine the relative protein amount. Spectral counting has demonstrated a high correlation with protein abundance; however, to achieve good quantitation accuracy with the technique, high speed MS/MS data acquisition is required. Moreover, manipulations of the exclusion/inclusion strategy also affect the accuracy of spectral counting significantly. Because peptide level quantitation is also important for post-translational modification studies, the accuracy of spectral counting on peptide level quantitation deserves further study.Another type of quantitation analysis determines peptide abundance by MS¹ peak signals. According to some studies, MS¹ peak signals across different LC-MS/MS runs can be highly reproducible and correlate well with protein abundance in complex biological samples (7–9). Quantitation analysis methods based on MS¹ peak signals can be classified into three categories: identity-based, pattern-based, and hybrid-based methods (16). Identity-based methods (7–9) depend on the results of MS/MS sequencing to identify and detect peptide signals in MS¹ data. However, because the data acquisition speed of MS scanning is insufficient, a considerable number of low abundance peptides may not be selected for limited MS/MS sequencing. Only a few peptides can be repetitively identified in all LC-MS/MS runs and subsequently quantified; thus, only a small fraction of identified peptides are quantified, resulting in a small number of quantifiable peptides/proteins.In contrast to identity-based methods, pattern-based methods (17–23), including the publicly available MSight (20), MZmine (21, 22), and msInspect (23), tend to quantify all peptide peaks in MS¹ data to increase the number of quantifiable peptides. These methods first detect all peaks in each MS¹ data and then align the detected peaks across different LC-MS/MS runs. However, in pattern-based methods, efficient detection and alignment of the peaks between each pair of LC-MS/MS runs are a major challenge. To align the peaks, several methods based on dynamic programming or image pattern recognition have been proposed (24–26). The algorithms applied in these methods require intensive computation, and their computation time increases dramatically as the number of compared samples increases because all the LC-MS/MS runs must be processed. Therefore, pattern-based approaches are infeasible for processing a large number of samples. Furthermore, pattern recognition algorithms may fail on data containing noise or overlapping peptide signal (i.e. co-eluting peptides). The hybrid-based quantitation approach (16, 27–30) combines a pattern recognition algorithm with peptide identification results to align shifted peptides for quantitation. The pioneering accurate mass and time tag strategy (27) takes advantage of very sensitive, highly accurate mass measurement instruments with a wide dynamic range, e.g. FTICR-MS and TOF-MS, for quantitation analysis. PEPPeR (16) and SuperHirn (28) apply pattern recognition algorithms to align peaks and use the peptide identification results as landmarks to improve the alignment. However, because these methods still align all peaks in MS¹ data, they suffer the same computation time problem as pattern-based methods.To resolve the computation-intensive problem in the hybrid approach, we present a fully automated software system, called IDEAL-Q, for label-free quantitation including differential protein expression and protein modification analysis. Instead of using computation-intensive pattern recognition methods, IDEAL-Q uses a computation-efficient fragmental regression method for identity-based alignment of all confidently identified peptides in a local elution time domain. It then performs peptide cross-assignment by mapping predicted elution time profiles across multiple LC-MS experiments. To improve the quantitation accuracy, IDEAL-Q applies three validation criteria to the detected peptide peak clusters to filter out noisy signals, false peptide peak clusters, and co-eluting peaks. Because of the above key features, i.e. fragmental regression and stringent validation, IDEAL-Q can substantially increase the number of quantifiable proteins as well as the quantitation accuracy compared with other extracted ion chromatogram (XIC)¹ -based tools. Notably, to accommodate different designs, IDEAL-Q supports various built-in normalization procedures, including normalization based on multiple internal standards, to eliminate systematic biases. It also adapts to different fractionation strategies for in-depth proteomics profiling.We evaluated the performance of IDEAL-Q on three levels: 1) quantitation of a standard protein mixture, 2) large scale proteome quantitation using replicate cell lysate, and 3) proteome scale quantitative analysis of protein expression that incorporates an additional fractionation step. We demonstrated that IDEAL-Q can quantify up to 89% of identified proteins (703 proteins) in the replicate THP-1 cell lysate. Moreover, by manual validation of the entire 11,940 peptide ions corresponding to 1,990 identified peptides, 93% of peptide ions were accurately quantified. In another experiment on replicate data containing huge chromatographic shifts obtained from two independent LC-MS/MS instruments, IDEAL-Q demonstrated its robust quantitation and its ability to rectify such shifts. Finally, we applied IDEAL-Q to the THP-1 replicate experiment with an additional SDS-PAGE fractionation step. Equipped with user-friendly visualization interfaces and convenient data output for publication, IDEAL-Q represents a generic, robust, and comprehensive tool for label-free quantitative proteomics.     

Type of Practice of Physicians in California,Report of the Bureau of Research and Planning

The total number of non-federal^* physicians in California rose from 23,065 in mid-1959 to 26,271 in January, 1962, an 11.3 per cent increase. The proportion of physicians in private active practice remained almost constant during this period.A significant rise, both in number and proportionally, took place in the full-time specialty category, offset by losses in the general practice-part-time specialty group. While specialists increased by over 30 per cent, general practitioners, who made up 31.7 per cent of all non-federal physicians in 1959, were only 24.7 per cent of the total in early 1962.     

Characterization of diabetes following pancreatic surgery in patients with congenital hyperinsulinism

Background

Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycaemia in infancy that leads to unfavourable neurological outcome if not treated adequately. In patients with severe diffuse CHI it remains under discussion whether pancreatic surgery should be performed or intensive medical treatment with the acceptance of recurrent episodes of mild hypoglycaemia is justified. Near-total pancreatectomy is associated with high rates of insulin-dependent diabetes mellitus and exocrine pancreatic insufficiency. Little is known about the management and long-term glycaemic control of CHI patients with diabetes after pancreatic surgery. We searched the German/Austrian DPV database and compared the course of 42 CHI patients with diabetes to that of patients with type 1 diabetes mellitus (T1DM). Study groups were compared at diabetes onset and after a follow-up period of 6.1 [3.3–9.7] (median [interquartile range]) years.

Results

The majority of CHI patients with diabetes were treated with insulin (85.2% [70.9–99.5] at diabetes onset, and 90.5% [81.2–99.7] at follow-up). However, compared to patients with T1DM, significantly more patients in the CHI group with diabetes were treated with conventional insulin therapy (47.8% vs. 24.4%, p?=?0.03 at diabetes onset, and 21.1% vs. 6.4% at follow-up, p?=?0.003), and only a small number of CHI patients were treated with insulin pumps. Daily insulin dose was significantly lower in CHI patients with diabetes than in patients with T1DM, both at diabetes onset (0.3 [0.2–0.5] vs. 0.6?IE/kg/d [0.4–0.8], p?=?0.003) and follow-up (0.8 [0.4–1.0] vs. 0.9 [0.7–1.0] IE/kg/d, p?=?0.02), while daily carbohydrate intake was comparable in both groups. Within the first treatment year, HbA1c levels were significantly lower in CHI patients with diabetes (6.2% [5.5–7.9] vs. 7.2% [6.5–8.2], p?=?0.003), but increased to a level comparable to that of T1DM patients at follow-up. Interestingly, in CHI patients, the risk of severe hypoglycaemia tends to be higher only at diabetes onset (14.8% vs. 5.8%, p?=?0.1).

Conclusions

In surgically treated CHI patients insulin treatment needs to be intensified in order to achieve good glycaemic control. Our data furthermore emphasize the need for improved medical treatment options for patients with diazoxide- and/or octreotide-unresponsive CHI.

     

Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study

Background

Thrombolysis for acute ischemic stroke has remained controversial. The Canadian Alteplase for Stroke Effectiveness Study, a national prospective cohort study, was conducted to assess the effectiveness of alteplase therapy for ischemic stroke in actual practice.

Methods

The study was mandated by the federal government as a condition of licensure of alteplase for the treatment of stroke in Canada. A registry was established to collect data over 2.5 years for stroke patients receiving such treatment from Feb. 17, 1999, through June 30, 2001. All centres capable of administering thrombolysis therapy according to Canadian guidelines were eligible to submit patient data to the registry. Data collection was prospective, and follow-up was completed at 90 days after stroke. Copies of head CT scans obtained at baseline and at 24–48 hours after the start of treatment were submitted to a central panel for review.

Results

A total of 1135 patients were enrolled at 60 centres in all major hospitals across Canada. The registry collected data for an estimated 84% of all treated ischemic stroke patients in the country. An excellent clinical outcome was observed in 37% of the patients. Symptomatic intracranial hemorrhage occurred in only 4.6% of the patients (95% confidence interval [CI] 3.4%–6.0%); however, 75% of these patients died in hospital. An additional 1.3% (95% CI 0.7%–2.2%) of patients had hemiorolingual angioedema.

Conclusions

The outcomes of stroke patients undergoing thrombolysis in Canada are commensurate with the results of clinical trials. The rate of symptomatic intracranial hemorrhage was low. Stroke thrombolysis is a safe and effective therapy in actual practice.Thrombolytic therapy for stroke was first reported in 1958¹ and a subsequent small trial was reported in 1963² in the absence of brain parenchymal imaging but guided by angiography. The later arrival of CT scanning was an enabling technological event, and early dose-finding trials were begun in the 1980s,^3,4,5 with large randomized trials conducted a decade later. Results of randomized trials of streptokinase therapy for ischemic stroke were uniformly negative.^6,7,8 Results of trials of tissue plasminogen activator (tPA) were mixed in their respective primary analyses^{9,10,11,12,13} but overall showed a benefit that wanes as time from symptom to treatment elapses.^14,15 A meta-analysis of randomized controlled trials showed that 55 fewer patients per 1000 treated with tPA within 6 hours after stroke would be dead or dependent at the end of follow-up compared with patients given placebo.¹⁶ Nevertheless, use of thrombolysis for stroke remains controversial, particularly because it is unclear whether such a therapy that is dependent on time, technology and infrastructure can be broadly and safely applied.In Canada, tPA therapy for stroke was conditionally licensed in 1999. As a condition of approval, a prospective registry to monitor safety was mandated by the federal government. The Canadian Alteplase for Stroke Effectiveness Study (CASES) was launched to collect data on outcomes for all patients treated with tPA in Canada. The purposes of the study were (a) to assess the safety of alteplase for stroke in the context of routine care and (b) to assess whether efficacy demonstrated in randomized clinical trials could be translated into effectiveness in clinical practice.